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Clinical Reasoning: A 79-Year-Old Man With Subacute Onset Involuntary Facial Movements and Discoordination
Amara Plaza-Jennings1,2, Prashanth Rajarajan1,2, Meabh O'Hare1,2
1Department of Neurology, Mass General Brigham, Boston, MA.
Neurology
|August 7, 2026
Summary
A rare autoimmune neurological disorder caused central nervous system inflammation, leading to tremor and ataxia in a cancer patient. Early diagnosis via serum and cerebrospinal fluid studies is crucial for effective management.
Area of Science:
- Neurology
- Oncology
- Immunology
Background:
- Metastatic Merkel cell carcinoma can present with paraneoplastic neurological syndromes.
- Paraneoplastic neurological syndromes can manifest with diverse and severe symptoms, including movement disorders and ataxia.
- Distinguishing autoimmune neurological disorders from cancer progression or treatment side effects is clinically challenging.
Purpose of the Study:
- To present a case of a 79-year-old man with metastatic Merkel cell carcinoma who developed significant neurological symptoms.
- To discuss the differential diagnosis of acute-onset tremor, involuntary facial movements, and ataxia in the context of cancer.
- To outline the diagnostic workup, management strategies, and clinical significance of autoimmune neurological disorders presenting as paraneoplastic syndromes.
Main Methods:
- Clinical case presentation of a patient with metastatic Merkel cell carcinoma.
- Neurological examination detailing symptoms such as intention tremor, dysarthria, ataxia, and dysdiadochokinesia.
- Cerebrospinal fluid (CSF) and serum studies to identify central nervous system (CNS) inflammation, including lymphocytic pleocytosis and elevated protein.
- Brain MRI to rule out acute structural abnormalities.
Main Results:
- The patient presented with a 1-week history of bilateral extremity tremor and involuntary facial movements, exacerbated by purposeful movement.
- Neurological examination revealed intention tremors, dysarthria, ataxia, and sensory deficits.
- CSF and serum analysis confirmed CNS inflammation, leading to the diagnosis of an autoimmune neurological disorder.
- Brain MRI showed no acute abnormalities, supporting an inflammatory rather than structural etiology.
Conclusions:
- Autoimmune neurological disorders can present with significant movement abnormalities and ataxia in cancer patients.
- Diagnosis relies on a combination of clinical presentation, neurological examination, CSF analysis, and serum studies.
- Prompt identification and management of these paraneoplastic syndromes are essential for patient outcomes.
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